=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467764316
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROGRESS SPEECH & LANGUAGE PATHOLOGY CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2010
-----------------------------------------------------
Last Update Date | 11/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 217 W CERRITOS AVE
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92805-6549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-776-1231
-----------------------------------------------------
Fax | 714-776-0802
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2020 N BROADWAY STE 101
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92706-2622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-776-1231
-----------------------------------------------------
Fax | 714-776-0802
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | PETER JEONG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-542-1234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT 14047
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT 40121
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SP12464
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------